Give way to ambulance – by Iqra Nadeem

The memory of how a joyous weekend lasted with agonizing pain and excruciating sorrow is still vivid in my mind. The day we lost our little cousin who brought a smile to everybody’s face and the day the, otherwise, disunited family for once felt collective loss. We planned out a family vacation over a weekend and decided to take a trip to Murree and Islamabad with our maternal aunt and uncle and their two overexcited children. On our way back to Lahore and just as we were about to reach, their car underwent an accident on the GT road as a trolley hit the left side of the car’s behind. Little Ayesha, who was a beautiful 10 year old girl got hurt and started bleeding. The rest of the family got slightly injured; however, since Ayesha was the one sitting at the back left, she got hurt the most. We caught up with our car a little behind theirs and amidst the hue and cry, shifted Ayesha to our car and drove towards Lahore. We realized, it would be better to call an ambulance while we drove and shift Ayesha to the ambulance as it arrives. Consequently, the ambulance arrived and Ayesha along with her mother was moved to the ambulance. As I caught a glimpse of her, the little angel as drenched in blood and for the first time I realized the urgency of the moment and stared in disbelief at how a moment could change a life forever, if not take it away. We drove behind the ambulance and as we reached the toll plaza at the entrance to Lahore, we realized that the traffic area was jam packed with traffic and the ambulance was stuck. To make matters worse, any way that was available was obstructed by other cars and motorcyclists who were convinced that they had an equal right to the path available as much as the ambulance did. Minutes passed as my sight wandered around for any possible way out of the traffic jam and my heart pounded as I had mental flashes of Ayesha’s dribbling blood. After waiting for around ten minutes, my father and my uncle got outside of their cars and started pleading people to make way for the ambulance and move their cars around. The ambulance driver himself seemed helpless and it seemed like the red flashing light and the siren of the ambulance were futile. In a matter of minutes, Ayesha’s mother burst out of the back of the ambulance hyperventilating and crying out loud for help. Ayesha had lost too much blood and by the time the roads had cleared out, Ayesha was no more.

Each extra moment in an ambulance takes away a moment of life from an injured person. Hence, the ambulance transportation is a crucial part of pre-hospital care. According to a research done in the USA, “Average duration in minutes for urban, suburban, and rural ground ambulances for the total pre-hospital interval were 30.96, 30.97, and 43.17; for the response interval were 5.25, 5.21, and 7.72; for the on-scene interval were 13.40, 13.39, and 14.59; and for the transport interval were 10.77, 10.86, and 17.28”; thus showing that the most time taken in pre-hospital care is on scene and also during transport (Carr, Caplan and Pryor). In low income countries like Pakistan, matters are made worse due to the ignorant and apathetic behavior of the people along with obvious infrastructural and institutional loopholes in pre-hospital ambulance care. The road network infrastructure in Pakistan is poor even in some urban areas and major cities and gets worse in rural areas, thus connectivity becomes an issue in case of emergency medical service provision. Along with this, the poor quality of construction causes roads to be damaged after heavy rainfall or even after heavy traffic passes over them for a while. Consequently, road maintenance goes on as the traffic passes by, further aggravating the traffic congestion. Another, important factor that exacerbates the situation is the VIP culture in Pakistan. VIP movements have multiple times affected the flow of traffic and obstructed the path of ambulances across Pakistan. The political elite in this country are privileged enough to curb traffic flows and snatch away the layman‟s right to free passage. Furthermore, the realm of public health has a dearth of resources and funding in Pakistan. Thus, the number of hospitals and ambulances are not sufficient to cater to the growing population in Pakistan. Thus, multifarious factors including poor resource allocation, lack of funding, social attitudes and political privilege impact the free passageway for an ambulance, thus causing wastage of those lives that can be, otherwise, saved.

The first hour that an injured person spends in the ambulance is called the “golden hour” and is the most crucial time in saving a life (Bigdeli, Khorasani-Zavareh and Mohammadi).Therefore, effective Emergency Medical Services are imperative to save lives of citizens. According to a road manual by the World Health Organization (WHO), Emergency medical services hold paramount significance and are defined as:

“A formal system of emergency medical services (EMS) is usually one with ambulances and trained personnel, who work in an agency with some supervision and with a network of communications. Where no formal EMS exists, governments should make alternative arrangements to provide pre-hospital care. Ways can be found to build on existing, informal systems and harness community resources, such as training members of the public in basic first aid. Setting up formal EMS systems in urban areas and along major inter-urban roadways should also be explored. Cost should be one consideration, given the high cost of these systems” (World Health Organization).

This shows that WHO is convinced that government intervention is imperative in ameliorating the emergency medical service of a country. According to a World Bank report on Road Traffic Injury prevention, around 1.2 million lives can be saved and around 50 million people saved from disability if pre-hospital care and ambulance services were made more efficient (Elm).

The free passage of ambulances is hindered by infrastructural aspects, such as lack of urban and city planning of its population centers. The only city that was planned in Pakistan was Islamabad, while no other urban center was planned and hence is affected by erratic city expansion due to the population explosion in Pakistan. Thus, the road networks are poorly connected and there is also a discrepancy in rood network availability across provinces. Balochistan and FATA are neglected provinces and most of their areas are not even accessible through road networks, while Punjab is the only province where road connectivity has been improved over the years. Additionally, the infrastructure connecting rural centers to urban centers is limited and the accessibility to roads is further reduced in case of people residing in rural areas. This phenomenon is observed in other countries as well and a research proving rural and urban amenity provision discrepancy shows that the EMS service times varied for urban and inter-urban areas. This research was carried out in Iran to assess EMS provision in response to road accidents and showed that the ambulance transport time for interurban areas was 17.1 minutes while it was 6.3 minutes for urban areas; similarly, the response time was also greater on interurban roads. However, the on-scene time was lower for interurban roads due to traffic congestion on urban roads (Bigdeli, Khorasani-Zavareh and Mohammadi). Furthermore, the public health service provision is neglected in Pakistan and according to a World Bank report of 2014; Pakistan spends only 2.6% of its total GDP on public health, which depicts the poor state of affairs in the realm of public health (The World Bank). Thus, there is a lack of all sorts of medical facilities for the public including the number of hospitals, the availability of ambulances and medical equipment in hospitals, the availability of medical staff, etc. Additionally, the health sector is rife with corruption, thus the limited funding is further diminished as it reaches the roots of the health system. Consequently, the hospitals are health delivery units are often inaccessible by those who need them due to both poor facilities and difficulty in access.

There are various legal and institutional factors at play that are adversely affecting the free passage for the ambulances. There is no government regulatory body to keep a check on the emergency medical services in Pakistan and hence the emergency medical service providers often lack the professionalism that service delivery must include. The ambulance personnel is not efficiently trained on pre-hospital and trauma care neither are professional drivers hired to drive the ambulance. Moreover, although many improvements have been made with the beginning of the Rescue 11222 service in Pakistan, but some ambulance services have also been accused of nepotism in their service provision, hence the elite are once again more privileged in access to service delivery than the less influential and the poor.

The legal facet to the issue is that there is no law that penalizes motorists on obstructing the passage of ambulances. Thus, people who hinder the ambulance passage get away scot-free which also encourages others to follow suit. The traffic regulation mechanism also does not penalize these motorists.

The most important factor that exacerbates the situation of ambulance passage is the societal aspect. Pakistani nation has been a victim of terrorism over the past few years and the excessive and gruesome media coverage of terrorist attacks has caused a rapid desensitization to human loss amongst the public. Thus the public has become apathetic and until and unless tragedies like The Army Public School attack strike the nation, they don‟t feel the burden of concern and the urgency to change their mindsets. Moreover, there has not been enough awareness about lives lost due to blockage of ambulance pathways, thus the people don‟t realize the extent of harm that their road etiquettes can cause to those carried by the ambulances. There are no statistics available for this sort of loss since no quantitative research has been done on it. On the contrary, the western media avoids showing gruesome details following a terrorist attack and acts professional in terms of coverage. Therefore, the impact of human loss is felt more by the west than people in countries like Pakistan. As a result, people on the roads are simply indifferent to the predicament of those carried by the ambulance. Another important societal aspect is that Pakistani people shun individual responsibility. They do not feel responsible for what goes wrong; rather blame it on the system or the politicians. Therefore, a sense of individual responsibility needs to be inculcated in the people.

The remedies to this social malady are many and the urgency of the issue is such that immediate steps need to be taken, not only by the government, but media, civil society organizations and also the common people. In order to promote the notion of giving way to ambulances, the institutional, societal and structural issues must be catered to. According to an extensive study done on improving pre-hospital trauma care through emergency medical services, seven aspects were found to be crucial. These were the “administration and organization; the availability and distribution of resources; the staff qualification and competences; communication and transportation; involved organizations, attitudes of laypeople, interaction and common understanding” (Haghparast-Bidgoli, Hasselberg and Khankeh). It was found that health policy makers considered Emergency Medical Services (EMS) a less significant area since it‟s a free service, thus neglecting effective policy making and management in the area of EMS. In case of staff qualifications and competences, it was revealed that the staff was getting insufficient and outdated training and there was mistrust between the ambulance staff and the consultant physicians, thus adversely affecting the quality of pre-hospital care provided to patients. The shortage and misdistribution of resources was also observed to hinder effective health care processes as there was a shortage of professional ambulance staff, ambulances to be dispatched and also necessary ambulance equipment and drugs. Along with this, communication and transportation hold paramount importance in responding to emergency cases and it was found that insufficient radio coverage dampens communication efficiency and since large areas are not covered by radio coverage, it becomes almost impossible for ambulance staff to communicate with those in need. Additionally, the study pointed out the need for cooperation and coordination by various organizations that are involved in dealing with emergency cases. For example, the research mentions the Police department, Fire department and the Red Crescent. It happens so that each organization‟s representatives reach the emergency site at different times and the rules and procedures required for reporting by each department further elongates the interval in which the patient receives necessary care. The research report also presented the lay people‟s reaction to emergency situation and mentioned how they interfere with the pre-hospital care by gathering around the patient and sometime even become the reason for secondary injuries. Along with this, poor infrastructure has a major role to play in delivery of EMS and factors such as “lack of GPS system, sub-standard road infrastructures (including lack of an emergency lane in cities and free-ways outside cities), lack of infrastructures for helicopter ambulances in the big cities, and an inadequate telecommunication system” further deteriorated public health service provision (Haghparast-Bidgoli, Hasselberg and Khankeh). Lastly, the common understanding of EMS is poor amongst the different actors involved; hence their coordination could be improved by creating awareness about the dire nature of urgency that EMS prevails and the knowledge and skills that hospital staff needs to possess to cater to such cases (Haghparast-Bidgoli, Hasselberg and Khankeh).

Therefore, first, the government must invest in improving infrastructure for better delivery of Emergency Medical Services and thus build efficient road and rail networks across the country without giving preferential treatment to one province or urban centers. Hence, connectivity between cities as well as rural centers needs to be improved. Also, the principles of urban planning must be put to use in major urban centers to improve resource allocation. The budget expenditure on public health must simultaneously increase and accountability and transparency must be ensured in the health sector by the introduction of checks and balances. The facilities provided by the health sector need to be focused on such that necessary equipment and drugs are available for use. In the west, helicopter ambulances are an effective and immediate means of providing pre-hospital care, therefore government health organizations in Pakistan should invest in arranging such facilities for the Pakistani people as well. Moreover, Private investments in the health sector should also be encouraged by the government by providing them incentives. Moreover, an EMS (Emergency Medical Service) Regulatory body must be founded that monitors the performance of ambulance companies and set performance standards for them along with penalties, in case, these standards are not met (World Health Organization). Along with this, ambulance personnel must be professionally trained for their job so that their ability to give pre-hospital care is improved. It was also found that failure to properly use the GPS caused delays in response time for ambulances; therefore GPS training must be included in personnel training (Haghparast-Bidgoli, Hasselberg and Khankeh).

Legislative measures also need to be introduced in order to minimize ambulance passage obstructions. Penalties in form of fines, license revocations, etc. must be imposed on motorists not giving way to the ambulance or hindering its passage. For example, in Australia, the Ambulance Service Act of Queensland was introduced in 1991, that ensures that all those in need of an ambulance would be provided by the service and no obstruction in service delivery would be tolerated (Queensland Authorities). Such laws are also present in countries like the United States of America and Canada and are known by the name of “move over laws”. The Move over laws require vehicles to change lane or move over as approached by emergency vehicles, including police cars, fire brigades and ambulances. These laws exist in France under the name: “Corridor de sécurité” (Move Over Laws). Moreover, research shows that ambulance staff is highly vulnerable to abuse. A survey conducted in Karachi showed that 36% of ambulance staff has face verbal abuse while 22% faced physical abuse and 60% of the times, the abusers were the attendants of the patients themselves and got violent due to delays in care provision or traffic congestion. Therefore, legislation must also grant protection to the innocent ambulance staff and fines or penalties must be imposed on people who harass the staff (Khatri).

Technology can be used as an effective means of minimizing ambulance passage hindrances. The growth of Information and Communication Technology for Development (ICTD) has seen a massive rise over the past decade and its application feasibility in the third world has also proved to be favorable. Technologies pertinent to traffic systems have been effective in making way for ambulances in the west and similar systems could be employed in Pakistan. According to a report on Rescue 1122 in Pakistan, an efficient technology was proposed by the name of Intelligent Traffic System. The system worked on the following principle:

“This system was based on the deployment of blue lights with directional display on polls which have embedded Wi-Fi cards. These polls can receive communication from an incoming ambulance from distances varying between 500 meters to 100 meters. The traffic warden on seeing blue illuminating light and the direction of arrival assigns priority to that link. This helps the traffic to be cleared up in a faster way and at the same time encourages other vehicles to accommodate and facilitate arriving vehicle” (Akbar).

Another very interesting technology proposed in India uses the combination of Internet of Things (IoT) and embedded systems to clear out pathways of ambulances by switching traffic signals to green on the route of the ambulance while switching other traffic signals to red that might cause hindrance to the ambulance path. This technology involves connecting the ambulance with the traffic signal boards through Bluetooth or Radio frequency connections and as the driver of the ambulance approaches a signal board, the ambulance route is fed into the system by tracking its GPS and all the signal boards that fall onto the route are re-timed according to the speed of the ambulance ensuring that the ambulance does not get stuck between vehicles stopping at a traffic signal (Venkatash, Shrivasta and Jagadish). Similarly, mobile technologies can also be used to enhance the flow of traffic as an ambulance approaches. This could potentially involve mobile applications that caution the vehicle drivers around an ambulance to make way for it. Again, this could be based on Wi-Fi or Bluetooth connections and mass awareness campaigns can be used to publicize such mobile applications and ensure that all drivers have them in their phones. This is feasible for Pakistan as well since the number of people buying android phones in Pakistan has grown exponentially over the years. Thus, technology can be a very useful tool in clearing up ambulance passage despite traffic congestion and the government must explore such technologies and their application in the public sector.
Institutional, structural and legislative endeavors would not bear fruit until the societal mindsets and behaviors are changed regarding the due priority of ambulance movement compared to the movement of other vehicles. It is true that this attitude has become a norm in our society and it takes years to mend societal norms, however, it is possible and can be done through the means of education and awareness. A well-designed mass awareness campaign needs to be initiated with the full support of government as well as private EMS agencies that specifically highlight the significance of giving way to an ambulance. Blood drive campaigns use an effective method for calling out to people which entails mentioning the average number of lives one can save if one donates blood, similar research needs to be done for giving way to ambulances. For instance, how many lives per minute are lost across Pakistan due to ambulance transportation delays or how many lives can be saved if one vehicle moves out of the way of an ambulance? Awareness campaigns need to be launched through digital media, social media and press media. These awareness campaigns should aim at imparting global citizenship education to the masses and hence inculcate social responsibility in them. Simple tricks and techniques on how to give way to an ambulance should be shared, for instance, move left, stop your car on the side and do not cross the ambulance, etc. Such campaigns have be done in Pakistan in the past and have proved to be very effective, for example the „Rasta Dein‟ film campaign that was brought to the forefront by a collaboration between the International Committee of the Red Cross (ICRC) and City Lights Productions (Khatri). This campaign used pathos and emotionally stirred the public to create awareness about giving way to the ambulance and saving lives. An observational study was conducted in Karachi to assess the impact of awareness campaigns by monitoring the change in number of vehicles that give way to an ambulance over time. This observational study was a result of ICRC‟s Healthcare in Danger project and after a mass awareness campaign was conducted in Karachi for 15 days in March 2016; 245 observations were made before, during and after the campaign to monitor the results. The slogan used during the campaign was “Give way to the ambulance; it may be carrying someone close to you” (Shaikh, Baig and Polkowski). The results were revealing and showed that only 60.8% vehicles gave way to an ambulance before the campaign, while during the campaign the percentage grew to an impressive 79.7%. The percentage fell to 77% after the campaign had ended. Hence, this study proves the effectiveness of mass awareness campaigns since a behavioral improvement of 16-18% from the baseline was observed (Shaikh, Baig and Polkowski).

A more qualitative research was done in Pakistan that provided insights into the ambulance usage in Karachi. It discovered, that the public have a general mistrust of the ambulance service in Pakistan and felt that their performance was not up to mark as compared with international standards. The study also depicted that the Pakistani public did not completely comprehend the need of ambulances in the health care infrastructure (Chandran, Ejaz and Kirani). Therefore, it is important to build the public‟s trust about EMS provision and the significant role that ambulances play in saving lives. This theme could also be incorporated in the awareness campaigns for ambulances. Furthermore, the information about the need and urgency to provide space to ambulances and how it can be done should be made a part of the school curriculum, so that children can be educated about this issue from their school days.

To conclude, a multifarious set of factors are involved in ambulance passage obstructions and although, the attitudes of the masses and the set infrastructure cannot be changed immediately, but we can train our future generations to respect the purpose an ambulance serves, hence facilitate and accommodate it in all sorts of settings. Mass awareness campaigns can be used to educate the masses as well as create empathy amongst them. The notion that somebody we love might get affected, stirs an immediate positive response driven by emotions that people do not otherwise have. In this context, ignorance seems to be the culprit. Therefore, ignorance has to be rooted out of the system along with structural, legislative and institutional changes to facilitate ambulance movement. Furthermore, people from all walks of life must come together to endorse this cause and ensure that they adhere to this theme in their daily lives. Along with this, a general attitude to assist and help needs to develop amongst our people. Mo matter what the emergency or what the situation, people tend to complicate scenarios, for instance by huddling around an injured person and worsening traffic jams, thus affecting ambulance accessibility. Hence, the sensibilities of the masses need to be touched for this campaign that should aim at incorporating empathy and kindness in their overall behavior. To put it in a nutshell, technological, legislative, structural and educational measures can be taken to ensure that ambulances are given way and lives are saved.